Refractory GERD patients not responding to BID proton pump inhibitors are often referred for anti-reflux surgery. Over the last 40 years, I have learned the importance of a team approach with comprehensive esophageal testing to appropriately find the patients who will benefit from surgery. All patients need upper endoscopy, high-resolution manometry and prolonged pH testing. Selected patients may need a barium esophagram or gastric emptying testing. All complex cases are discussed at our weekly esophageal conference which includes gastroenterologists, foregut surgeons and swallowing therapists. Ten case scenarios are presented of recurrent themes in patients with “refractory” GERD, many whom don’t have acid reflux.
TargownikLEMergeCRoosLLeungS.The prevalence of and the clinical demographic characteristics associated with high-intensity PPI use. Am J Gastroenterol. 2007;102:942-950.
2.
CamposGMPetersJHDeMeesterTR, et al. Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg. 1999;3:292-300.
3.
SoJBZeiteisSMRattnerDW.Outcomes of atypical symptoms attributed to gastroesophageal reflux disease treated by laparoscopic fundoplication. Surgery. 1998;124:28-32.
4.
LodrapAPottegardAHallasJBytzerP.Use of proton pump inhibitors after anti-reflux surgery: a nationwide register-based follow-up study. Gut. 2014;63:1544-1549.
5.
SavarinoEde BortoliNDeCassanC, et al. The natural history of gastro-esophageal reflux disease: a comprehensive review. Dis Esophagus. 2017;30:1-9.
6.
GyawaliCPKahrilasPJSavarinoE, et al. Modern diagnosis of GERD: the Lyons Consensus. Gut. 2016;67:1351-1362.
7.
HasakSYadlapatiRAltayarO, et al. Prolonged wireless pH monitoring in patients with persistent reflux symptoms despite proton pump inhibitor therapy. Clin Gastroenterol Hepatol. 2020;18:2912-2919.
8.
PatelRChaeSKumarARichterJE.Sedation and afternoon placement of the 48-hour wireless ambulatory pH capsule results in more reflux on the first day. J Clin Gastroenterol. 2017;51:594-598.
9.
PatelRKumarAChaeS, et al. 96-hour esophageal pH monitoring: the tiebreaker for abnormal DeMeester score and symptom index. J Gastrointest Disorders. 2019;2:1008.
10.
SpechlerSJHunterJGJonesKM, et al. Randomized trial of medical versus surgical treatment for refractory heartburn. N Engl J Med. 2019;281:1513-1523.
11.
PauwelsABoecvstaensVAndrewsCN, et al. How to select patients for anti-reflux surgery? The ICARUS guidelines (International consensus regarding preoperative examinations and clinical characteristics assessment to select adult patients for anti-reflux surgery). Gut. 2019;68:1928-1941.
12.
ChanWWHaroianLRGyawaliCP.Value of preoperative esophageal function studies before laparoscopic anti-reflux surgery. Surg Endosc. 2011;25:2943-2949.
13.
RichterJEClaytonSB.Diagnosis and management of esophagogastric junction outflow obstruction. Am J Gastroenterol. 2019;114:545-547.
14.
YadlapatiRKahrilasPJFoxMR, et al. Esophageal motility disorders on high-resolution manometry. Chicago classification version 4.0. Neurogastroenterol Motil. 2021;33:e14058.
15.
ViljakkaMSaaliKKoshinenM, et al. Anti-reflux surgery enhances gastric emptying. Arch Surg. 1999;134:18-21.
16.
PohCHGasiorowskaANavaarro-RodriguezT, et al. Upper GI tract findings in patients with heartburn in whom proton pump inhibitor treatment failed versus those no receiving anti-reflux treatment. Gastrointestinal Endosc. 2010;71:28-34.
17.
RatnasingamDIrvineTThompsonDK, et al. Laparoscopic anti-reflux surgery in patients with throat symptoms: a word of caution. World J Surg. 2011;35:342-348.
18.
KrillJTNaikRDHigginbothamET, et al. Association between responses to acid-suppression therapy and efficacy of anti-reflux surgery in patients with extra esophageal reflux. Clin Gastroenterol Hepatol. 2017;15:675-681.
19.
GastalOLHagenJAPetersJH, et al. Short esophagus: analysis of predictors and clinical implications. Arch Surg. 1999;134:633-636.
20.
SwanstromLLMarcusDRGallawayGQ.Laparoscopic Collis gastroplasty in the treatment of choice for the shortened esophagus. Am J Surg. 1996;171:477-481.
21.
WinslowER.Patients with upright reflux have less favorable postoperative outcomes after laparoscopic antireflux surgery than those with supine reflux. J Gastrointest Surg. 2002;6:819-830.
22.
KlausAHinderRADeVaultKRAchemSR.Bowel dysfunction after anti-reflux surgery: incidence, severity and clinical course. Am J Med. 2003;114:6-9.
